The ID assigned to the Patient for this survey.


General Instructions
(example text format)

  1. The participant can complete this questionnaire after instruction from the research nurse.
  2. The answers to this questionnaire are very important.  Please ensure all 18 questions are answered, if possible.  However, if the participant is feeling too exhausted or stressed to finish filling out this questionnaire please allow them to stop and rest.  If you can, complete the rest of the questionnaire on the same day.
  3. Please indicate the date that you fill out the form.
  4. Instruct the participant to complete the answers in the following manner.

It is important that you answer all questions for how you have been feeling just in the past 2 days

Example of multi-selection question:
Please select the things you like about this survey tool
(You may list as many as you like)
Your age group?
(Please select one from the list)